Denial Prevention Nurse Consultant

Ready to make a difference for hospitals while working from home? Start your next chapter at Revecore! For over 25 years, Revecore has been at the forefront of specialized claims management, helping healthcare providers recover meaningful revenue to enhance quality patient care in their communities. We’re powered by people, driven by technology, and dedicated to our clients and employees. If you’re looking for a collaborative and diverse culture with a great work/life balance, look no further.

Primarily responsible for thorough review of medical records and other medical documentation to determine appropriate billable services for hospital to construct an appeal for payment based on medical necessity or payer specific guidelines or criteria. Responsible for providing clients trending, revenue cycle fail point analysis, and best practice remediation recommendations. Training: Our comprehensive training begins on your first day and lasts 90 business days. It is led by instructors and incorporates interactive discussions and hands-on activities to accommodate diverse learning preferences.

Build strong, lasting relationships with clients, payors and Revecore personnel Analyze medical records or other medical documentation to validate services, tests, supplies and drugs performed for accuracy related to billing for services rendered Identify and interpret medical, radiological, laboratory or other tests and procedures as well as pharmaceutical drugs Review and understand managed care contracts, hospital billing statements/bills and insurance denials Research commercial and governmental payor policies, clinical abstracts and studies, and other documentation related to claims payment to evaluate and appeal denied claims. Perform research regarding denials and effectively communicate information to associates, colleagues, managers and clients Contact insurance company to obtain missing information, explain and resolve underpayments and/or denials and arrange for payment or adjustment processing on behalf of client Prepare and submit correspondence such as letters, emails, online inquiries, appeals, adjustments, reports and payment posting Perform denial trending for clients, identify fail points within the revenue cycle and on the payer side, and provide best practice recommendations to clients and Revecore managers. Maintain regular contact with necessary parties regarding claims status including payors, clients, managers, and other Revecore personnel Maintain confidentiality of information in compliance with company policy and HIPAA Attend client, department and company meetings Lead client meetings and perform consulting services to client’s as it relates to medical necessity of services performed and proper vetting of payers criteria